Outpatient Hosp Field Audit I

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

This position responsible for performing third party, outpatient APC & bill verification (CPT 4 coding experience required), credit balance and Ambulatory Surgery Center facility audits and provides guidance and instruction on payment and auditing, conducts desk audits, forms development, profiling and tracking institutional audit trends and statistical analysis of audit data.

Responsibilities:

• Performs third party, outpatient (APC & bill verification) credit balance ASC audits and special projects.

• Communicates with hospital (business office and health information management) personnel for purposes of case resolution and audit closure.

• Prepares data and assist in negotiating discounts with non-select providers to bring audit to closure.

• Identifies and presents billing discrepancies found during bill verification and outpatient audits and coordinates referral of improper claim payments through the appropriate channels to credit savings to Plan accounts.

• Compiles statistics and other audit information to present to accounts, regulatory agencies, internal requesters and others.

• Discusses audit recommendations for new types of audit ventures with manager and obtains audit data for purposes of testing, performs in house investigations, on site test reviews and compilations of findings.

• Identifies error trends as they relate to medical record and/or billing documentation or misinterpretation of provider contract stipulations resulting in erroneous payments to institutional provider.

• Reviews and updates audit processes with manager for purposes of keeping up with new innovations in clinical data review and company cost containment initiatives and provides data to manager in determining cost effectiveness and return on investment of new innovations.

• Performs and process benefit compliance activities to ensure correct utilization of benefits.

• Claims investigation via payment systems (NASCO, QBLUE, ERISCO, UPS etc.)

• Demonstrates knowledge, understanding and conforms to laws, regulations and policies that pertain to the organizational units business.

Education/Experience:

• High School Diploma/GED required.

• RN with CCS certification preferred.

• Requires minimum of one (1) year experience in health care industry, preferably in audit or billing environment.

• Prefers exposure to CPT4 and HCPCS coding

Additional licensing, certifications, registrations:

• Preferred CPC, CPC-H or CCS certifications

Knowledge:

• Requires knowledge of company reimbursement methodology - Institutional Facilities.

• Requires knowledge of CPT-4 Coding principles.

• Requires in depth knowledge of institutional billing practices and charge-master (inpatient/outpatient).

• Requires in depth knowledge of company mainframe payment systems.

Skills and Abilities:

• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.

• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

• Proven time management skills are necessary.

• Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.

• Demonstrated ability to work in a production focused environment.

• Proven ability to exercise sound judgment and strong problem solving skills.

• Proven ability to ask probing questions and obtain thorough and relevant information.

• Must be client service focused with effective ability to empathize.

• Must be detail oriented with strong organizational and data processing skills.

• Proven ability to follow detailed instructions is essential, along with excellent math skills.

• Proven analytical, research and problem solving skills a must.

• Must demonstrate the ability to learn quickly and apply learning to new situations. Must exhibit flexibility to change as appropriate.

• Needs to demonstrate willingness to cross-train, and be cross-trained, in other roles/duties.

• Must have strong entrepreneurial business development, negotiation, relationship building, and networking skills.

Travel :

• Role is remote but requires occassional meetings in office.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

$62,100 - $83,160

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.